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"I?9-W(�2 <br />UNDERGROUND STORAGE TANK UNAUTHORIZED RELEASE (LEAK) / CONTAMINATION SITE REPORT <br />EMERGENCY HAS STATE OFFICE OF EMERGENCY SERVICES <br />REPORT BEEN FILED 7 <br />- FORLOCAL'AGENCYUSEONLY. <br />YES NO YES ❑ NO <br />INEREBY CERTIFYTHATLHAVE DISTRIBUTED THIS INFORMATION ACCORDING TO THE <br />REPORT DATt CASE <br />DISTR IBUTION SHOWN ON THE INSTRUCT)ON SHEET ON THE BACK PAGE OF THIS FOR M <br />;1 <br />9 <br />`✓ <br />SIGNED DATE <br />M M I Y <br />NAME OF INDIVIDUAL FILING REPORT <br />PHONE <br />SIGNATURE <br />w <br />i <br />REPRESENTING O OWNER'OPffQt6R ❑ REGIONAL BOARD <br />LOCAL AGENCY ❑ OTHER Is, <br />COMPANY OR AGENCY NAME , J <br />�•. ��J N D <br />ADDRESS <br />�D <br />STREET cm• yTATE <br />NAM <br />CONTACT PERSONp <br />PHONE <br />Z <br />,I _ <br />Ll. �) ' ❑ UNKNOWN <br />( ) <br />y u <br />ADDRESS <br />71 IvPst' �a� /} • V.`ne�a.�1�L N- <br />sTREU cm STATE p <br />FACILITY NAME (IF APPLICABLE) <br />OPERATOR PHONE <br />� /r <br />aADDRESS <br />STREUCm cmNTV p <br />m <br />GROSS -STREET <br />J <br />O <br />waf� <br />LOCALAGENGY AGENCY NAME <br />CONTACT PERSON <br />PHONE <br />w <br />REGIONAL BOARD <br />PHONE <br />a a <br />1 111 1 � <br />w <br />w <br />OI NAME OUANT)TY LOST (GALLON ) <br />�`^' <br />F J <br />�✓ +C� p�C/� ` ❑ UNKNOWN <br />O <br />]Z <br />MryJJ <br />„) <br />w <br />❑ UNKNOWN <br />i <br />DATE DISCOVERED <br />II '�C'/ <br />HOW DISCOVERED INVENTORY CONTROL E] SUBSURFACE MONITORING ❑ NUISANCE CONDITIONS <br />o r �+ v <br />❑ TANK TEST ❑ TANK REMOVAL iz OTHER JaJ2 Sod S <br />Q <br />DATE DISCHARGE BEGAN <br />METHOD USED TO STOP DISCHARGE (CHECK ALL THAT APPLY) <br />w <br />M M .1 YlI UNKNOWN <br />REMOVE CONTENTSCLOSE TANK & REMOVE E]REPAIR PIPING <br />S2 <br />❑ REPAIR TANK ❑ CLOSE TANK & FILL IN PLACE E:] CHANGE PROCEDURE <br />HAS DISCHARGE BEEN STOPPED?REPAIR (/� <br />VES IF 9 ao �r <br />[—]ND YES, DATE IOM <br />❑REPLACE TANK ❑OTHER <br />1 Y <br />SOURCE OF DISCHARGE <br />CAUSE(S) <br />❑ TANK LEAK UNKNOWN <br />❑ OVERFILL ❑ RUPTURE/FAILURE ❑ SPILL <br />00 <br />❑ PIPING LEAK ❑ OTHER <br />❑ CORROSION UNKNOWN ❑ OTHER <br />a n <br />CHECK ONE ONLY <br />O <br />❑ UNDETERMINED SOIL ONLY ❑ GROUNDWATER ❑ DRINKING WATER - (CHECK ONLY IF WATER WELLS HAVE ACTUALLY BEEN Al <br />FECTED) <br />CHECK ONE ONLY <br />z� <br />F-1NO ACTION TAKEN ❑ PRELIMINARY SITE ASSESSMENT WORKPLAN SUBMITTED E:] POLLUTION CHARACTERIZATION <br />Dy <br />0 <br />LEAK BEING CONFIRMED F-1PRELIMINARYSITE ASSESSMENT UNDERWAY ❑ POST CLEANUP MONITORING IN PROGRE' <br />❑ REMEDIATION PLAN ❑ CASE CLOSED (CLEANUP COMPLETED OR UNNECESSARY) O CLEANUP UNDERWAY <br />J <br />CHECK APPROPRIATE TION(S) EXCAVATE & DISPOSE (ED) ❑ REMOVE FREE PRODUCT (FP) ❑ ENHANCED BIO DEGRADATION(IT) <br />50 <br />w <br />F-1CAP SITE (CD) EXCAVATE& TREAT (ET) ❑ PUMP& TREAT GROUNDWATER (GT) REPLACE SUPPLY (RS) <br />¢a <br />❑ CONTAINMENT BARRIER (CB) ❑ NO ACTION REQUIRED (NA) <br />E](OOT)TREATMENT AT HOOKUP (HU) ❑ VENT SOIL (VS) <br />❑ VACUUM EXTRACT(VE) OTHER <br />N <br />� <br />�® )���)' <br />��^/�/y)�` �v� �/ �W�� /W�/�/•�/✓_) — /' .env .✓(i/v� f% Wf/(/�,J,��/{ SIIi'y///��/1��/✓✓✓``��'���__///`✓✓✓jj�///�.��.�����'--- <br />� �`<C�%����'" <br />�' <br />� <br />O <br />Vvv � '{�������� / (/fes/K� (..I IY W r ' _ �V - / � •I _ <br />H$c 0.5189% <br />